TN 8 (08-10)
DI 20503.001 Documenting the Disability Folder – Disability Determination Services (DDS)
A. Policy on material in disability folders
All disability folders (e.g., electronic, modular, and two-part brown) must contain material that documents the development steps and is:
NOTE: The claimant’s file is a legal document and must reflect an objective assessment. Avoid subjective comments that may be interpreted as bias.
B. What is essential material and relevant evidence
1. Definition of essential material
Essential material is necessary to make the disability determination and applies to certified electronic folders (CEFs), Modular Disability Folders (MDFs), and brown, non-MDF folders used prior to the inception of the MDF. Essential material includes:
The Case Development Summary worksheet (or any other documentation describing the development steps completed);
All unproductive requests (discard consultative examination (CE) notices to the medical source, regardless of whether the claimant kept the appointment).
DI 20503.001E – What is the Case Development Summary Worksheet;
DI 81020.065 – Electronic Case Documentation;
DI 81020.230 – Documenting Comparison Point Decision (CPD) Evidence and Preparing the Electronic Continuing Disability Review (eCDR) Rationale.
2. Definition of relevant evidence
Relevant evidence is a type of essential material that is relevant to the issues in the case, including, but not limited to:
Establishing a medically determinable impairment (s);
Establishing the onset date of disability;
Documenting fraud or similar fault (FSF) (See DI 23025.000 for documentation instructions for claims involving FSF).
C. Procedures for handling essential material
Disability examiners (DEs) must adhere to the following guidelines for handling essential material in CEFs and MDFs:
Organize material in chronological order by date received at each level of the process, unless otherwise noted. (See DI 70005.005 – General Overview of the MDF);
Include Form SSA-887 - Summary of Evidence (or an equivalent form based on your local business process) for pre-Disability Hearings Unit claims;
Retain Form SSA-448- Request for Medical Advice, or Form SSA-416- Medical Evidence (or local equivalent form(s)) in the folder. (These forms document communication between the DE, medical consultant, psychological consultant, and medical advisor, and they are essential to making the disability determination).
D. What is nonessential material and irrelevant evidence
1. Definition of nonessential material
Nonessential material does not serve to document the disability determination, is of no value for future reviews, and should be discarded. This definition applies to material in:
NOTE: If in doubt as to whether evidence is essential or nonessential, the disability adjudicator must keep the evidence in file.
2. What includes nonessential material
Nonessential material includes:
Duplicate medical evidence;
Internal DDS routing and case management slips;
Blank form(s) included with letters to claimants, medical sources, third parties, etc. if identified in the list of notice enclosures (e.g., “Enclosure: SSA-3369BK (Work History Report), SSA-3380BK (Function Report Adult Third Party”); and
Irrelevant evidence (see DI 20503.001D.3. for definition)
DI 70005.005 – General Overview of the MDF
3. Definition of irrelevant evidence
Irrelevant evidence is material that does not meet the definition of “relevant evidence” as described in DI 20503.001B.2.
4. Who determines what evidence is irrelevant
Only the DE making the determination on a case may decide which evidence is relevant or irrelevant. The DE cannot delegate this decision to anyone who is not making a determination on the case. Once the DE decides what evidence is irrelevant, any staff may carry out the handling and retention procedures.
NOTE: When the hearing office initiates an assistance request to the DDS, the DDS DE does not determine the relevancy of the evidence.
5. What to do when an electronic document contains both relevant and irrelevant evidence
When an electronic document contains both relevant and irrelevant evidence, adjudicators must:
Create a new document for the relevant evidence by following the instructions in DI 81020.065E.3. – Electronic Case Documentation; and
Annotate on the Worksheet the new document containing only relevant evidence; annotate the original document from which the relevant evidence was extracted and describe briefly the materials not retained in file, including the type of material and the reason for discarding it (e.g., duplicate medical evidence received from different sources).
Move the original document containing both relevant and irrelevant evidence into the green section (Current Development/Temporary) of the CEF. All material in the green section of the CEF will automatically be discarded after all quality reviews applicable to the current level of adjudication are completed.
NOTE: Page-level manipulation is dependent on the DDS’s jurisdictional control of the document. See, to access the link to the DMA Viewer Functionality Guide for the procedure titled “Page-Level Manipulation for instructions on: http://sharepoint.ba.ssa.gov/DCS/OESAE/DEDMS/DEDMSHome/DMA/Guides/DMA 09.2 Viewer Guide April 2014.doc
Rearranging the order of pages in a multi-page document;
Removing a page within a multi-page document;
Copying or moving pages from one document to another; or
Creating a new document by copying or moving pages from one document to the newly created document
6. What to do with nonessential material
After all quality reviews related to the current level of adjudication are complete, DE’s must:
Discard nonessential material in a manner that prevents unauthorized disclosure according to the instructions in DI 81020.055 – Document Retention and Destruction. (For MDFs see, DI 39567.220C – Disposal of Paper Records);
Include a brief description of material not retained in file, including the type of material and the reason for discarding, e.g., duplicate medical evidence received from the same source;
Retain any irrelevant evidence received as part of an informal remand unless a wholly favorable determination is effectuated.
7. Discarding nonessential material from the CEF
Move the material to the green (Current Development/Temporary) section of the CEF. All material in the green section of the folder is automatically discarded after all quality reviews are complete.
NOTE: Do not delete nonessential material from a CEF (e.g. using the computer’s delete button) at any time.
8. Discarding nonessential material from the paper MDF
When discarding nonessential material from the MDF:
Label material “Nonessential Material - Destroy After All Reviews Have Been Completed” (see exhibit of sample Nonessential Material flag in DI 20503.010); and
Place in the green section (Current Development/Temporary) of the MDF; or
Attach to the file if there is not enough room in the green section.
When all actions at the current level of adjudication are complete, including the component review, the office taking the last action will discard the material marked with the Nonessential Material flag.
E. What is the case development summary worksheet
1. Definition of the case development summary worksheet
The Case Development Summary is a worksheet the DE prepares to:
Document all disability development undertaken;
Record the receipt or non-receipt of requested evidence;
Describe any material not kept.
2. Procedure for handling the worksheet
Permanently retain the worksheet as the top document in the Medical Records (Yellow/Back) section of the MDF or the CEF. Fully document all development pertaining to the current decision on the worksheet if development requests are not in file.
DI 20503.005 for an exhibit of a Model Case Development Summary worksheet.
3. How to prepare a worksheet
When preparing the Case Development Summary worksheets ensure that:
All entries are precise and easily understood by subsequent reviewers and adjudicators, including quality reviewers, administrative law judges and the Federal courts.
The entries stand alone and do not require a coding key or interpretive guide to decipher (i.e., no encrypted entries).
DE’s complete a new worksheet form at each level of adjudication through the disability hearing officer level.
Locally created DDS development forms must contain the required claimant and development information described in DI 20503.001E.3. - DI 20503.001E.6.
4. Required claimant information on the worksheet
The following claimant information is required and must be entered on the Case Development Summary worksheet:
Name and Social Security Number (SSN);
Date of Birth (DOB);
Representative information - i.e., attorney or other appointed representative;
Level of Claim – e.g., initial, reconsideration, CDR, etc;
Type of Claim – e.g., Disability Insurance Benefits (DIB), Childhood Disability Benefits (CDB), Disabled Window(er) Benefits (DWB), Disabled Individual (DI), Medicare for Qualified Government Employment.
NOTE: For DWB and CDB claims also enter the wage earner’s name and SSN.
5. Required development information on the worksheet
Document on the Case Development Summary worksheet initial and follow-up requests for MER and non-MER made by:
DI 20503.001F – Guidelines for retaining or discarding MER requests, CE notices, claimant requests, or third party requests;
DI 22505.006 – Requesting Evidence – General; and
DI 22505.035 – Follow-up on Requests for Medical Evidence of Record (MER).
6. How to document development steps on the worksheet
Enter the following information to document the development steps.
a. Brief explanation of development
Provide a brief explanation of development, such as:
Reason(s) the individual’s own medical source(s) was not used to perform a CE;
Reason(s) requested development was curtailed (e.g., sufficient but not all evidence obtained to support a determination as to disability). This is not necessary for fully favorable decisions.
b. Required entries for successful requests
The following entries for successful requests, if not retained in file, are required on the Worksheet to document development. These instructions apply to both initial and follow-up requests:
Date of the request;
Request method (i.e., phone, mail, or fax, ERE);
Names of all sources contacted;
Identification of Adjudicator (e.g., DE, DHO, etc.); and
Scheduled consultative examinations or tests requested and subsequently not required.
NOTE: In these instances, promptly notify the CE source that the examination or test is not required. In addition, promptly notify the claimant, and the claimant’s representative if applicable, that the examination or test has been cancelled. Annotate the worksheet accordingly, indicating the method of notification (e.g., phone, mail).
F. Guidelines for retaining or discarding MER requests, CE notices, claimant requests, or third party requests
1. Productive and unproductive requests for MER
a. Unproductive requests
For unproductive requests (i.e., no responses), or incomplete responses (i.e., lacking a relevant part), retain the MER request letter.
b. Productive requests
For productive requests:
Discard the MER request letter;
Annotate the Case Development Summary worksheet with “MO requested” if a medical opinion (MO) was not received; (A report is not considerd incomplete if a medical opinion was requested but not received. See DI 22505.007B.)
Annotate the worksheet with “CE interest requested” if the MER request to a medical source asked if the source is interested in performing a CE.
NOTE: The remarks “MO requested” and “CE interest requested” are not required on the worksheet until the DDS implements the necessary software to post these remarks automatically.
2. CE notices
a. To the claimant
b. To the medical source
Discard the CE notice to the medical source regardless of whether the appointment was kept. The CE notice to the medical source can be discarded because the corresponding CE notice to the claimant is retained if the appointment was not kept.
Annotate the worksheet as to why the individual’s own medical source(s) was not used for a CE.
3. Claimant requests
For unproductive requests, retain the request letter.
For productive requests, discard the request letter (e.g., requests for completion of an SSA-3373-BK - Function Report - Adult or SSA-3369BK-Work History Report, call-in letters, etc.)
4. Third party requests
For unproductive requests, retain the request letter.
For productive requests, discard the request letter (e.g., requests for completion of an SSA-3380BK-Function Report-Adult-Third Party Booklet, call-in letters, etc.)